Concussions, TBI, Reading, Balance, Car-Sickness, Attention, Visual Fatigue Problems Vision Therapy 101 for the Primary Care Practitioner By Stan Appelbaum, OD

1. Neurorehabilitation of Visual
Impairments
Field Defects – Diplopia – Balance –
Dizziness--Reading Problems
Stan Appelbaum, OD, FCOVD
Bryce Appelbaum, OD, FCOVD
Neuro Optometry & Vision Therapy
Bethesda & Annapolis, Maryland
301-897-8484
www.VisionHelp.com
www.AppelbaumVision.com
Visionary Ophthalmology
Rockville, Maryland
March 8, 2015

2. Concussions, TBI, Reading,
Balance, Car-Sickness,
Attention, & Visual Fatigue
Problems
Vision Therapy 101 for The
Primary Care Practitioner

3. Sept. 26, 2011
OT ADVANCE
cover story
”At First Sight”
Husband and wife team,
Stan Appelbaum, OD, FCOVD
& Barbara Bassin, OTR/L, BCP
practice with their son,
Bryce Appelbaum, OD, FCOVD

4. Sept/Oct 2014
Bethesda Magazine
Seeing Success:
Vision therapy is
helping patients get
their eyes back on
track
By Stacey Colino

5. Understanding and
Managing Visual &
Vestibular Deficits

6. This Seminar Will…
• Secure your
understanding of the
essential synchronicity
of visual and
vestibular function
• It will dispell that
myth that 20/20 is
perfect vision
• It will give you
practical testing and
treatment methods

7. Does 20/20 visual acuity insure
you can see a 3-ring circus?
What do you see in this picture?

8. Now do you see it?
Visual recognition is more than
detail detection

9. The visual brain is more than the
eyes and occipital lobe

10. Vision…More than acuity
• Vision is a process
• Good vision requires the effective input of
visual information
• Good vision requires the effective
processing and integration of visual
information
• Good vision is this culmination through
which we make use of visual information

11. BAOD Syndrome…
The vision triad that causes impairment
• Binocular
• Accommodative
• Oculomotor
Dysfunction

12. Vision…Input abilities
• Binocular control
Ranges of fusion and integration with
accommodation
• Accommodative control
Amplitude, flexibility/facility and
integration with binocular control
• Oculomotor control
Fixations, pursuits and saccades

13. King-Devick
• Relationship between poor ocular motor
abilities (ex. saccades) and reading efficiency
• Poorly on King-Devick are not efficient
readers
• Saccadic eye movements can be
improved with proper training
http://www.youtube.com/watch?feature=playe
r_embedded&v=c4k9f2QL7KI

15. "Studies have indicated that the King-Devick
test is an effective tool for the real-time
evaluation of concussion because it looks
at rapid eye movement and attention,
both of which are affected by
concussions," said Dr. David Dodick, a
neurosurgeon and the director of the
Mayo Clinic's concussion program in
Phoenix.
Mayo Clinic adds its
name to sidelines
concussion test

16. The King-Devick Test is a tool for
evaluation of saccadic fixations, consisting
of a series of test cards of numbers. The
test cards become progressively more
difficult to read due to variability of
spacing between the numbers. Both
errors in reading and speed of reading are
included in deriving a score. Saccades are
quick, simultaneous movements of both
eyes.

18. King Devick website

19. King Devick website

20. What is Visual Fitness & How May
It Be Affecting Your Life?
• Internet Eyes
• The Night-Driving Nightmare
• Counting the Pages
• Too Tired to Get a Life
• Sports Vision
• Wear Them—You’ll Get Used to Them
• Seeing to Sleep
• Developing Your Visual Fitness

21. 9 WAYS PEOPLE CAN BENEFIT
FROM VISION THERAPY
1) Improve vision related reading and learning
problems
2) Improve vision in "lazy eye" - Amblyopia
3) Correct cross or turned eyes – Strabismus
4) Enhance sports performance
5) Aid people after a stroke or brain trauma
6) Myopia (nearsightedness) prevention, control,
and reduction programs
7) Alleviate headaches from visual stress
8) Help tired eyes in the workplace
9) Improve skills in visually delayed children
www.VisionHelp.com

22. Binocular Function
• State of simultaneous vision, which is
achieved by the coordinated use of both
eyes so that separate and slightly
dissimilar images arising in each eye are
appreciated as a single image by the
process of fusion
• Achieved through a combination of
stereopsis, ocular alignment &
convergence

23. “Oculomotor dysfunctions are
among the most common vision
problems in individuals with
acquired brain injury (ABI).a
recent large-scale retrospective
study documented that
approximately 90% of individuals
with mild ABI or CVA manifested
some type of oculomotor
dysfunction after the acute phase
of care.”
Ciuffreda KJ, Kapoor N, et al. Occurrence
of oculomotor dysfunctions in acquired
brain injury: a retrospective analysis.
Optometry 2007;78:155-61

24. “There are an estimated 1,080,000
Americans that have experienced major
disruptions in their professional and
private lives because of vision changes
resulting from a head injury.”
Stroke. 1997; 28:284-290

25. “Up to a quarter of stroke
survivors may have vision
dysfunction”
National Stroke Association
www.stroke.org

26. There is an extremely high incidence
(greater than 50%) of visual and visual-
cognitive disorders in neurologically
impaired patients (traumatic brain injury,
cerebral vascular accidents, multiple
sclerosis etc.)
Rosalind Gianutsos, Ph.D.
Director, Cognitive Rehabilitation Services
Sunnyside, NY

27. A message from a TBI Survivor
“Society is more likely to take action
against the ravages of traumatic brain
injury if it understands how pernicious,
pervasive and huge the problem is.”
Claudia L. Osborn, DO, FACOI
College of Osteopathic Medicine, Michigan State
University

30. CDC 2013 Report to Congress
“Of the more than 2.5 million people
experiencing TBI each year in the United
States, it has been estimated that 75%
experience mTBI”

31. According to the US Centers for
Disease Control and Prevention
Mild traumatic brain injury (mTBI) is:
…”the occurrence of injury to the head arising
from blunt trauma or acceleration or
deceleration forces with one or more of the
following conditions attributable to the injury:
any period of observed or self –reported
transient confusion, disorientation or impaired
consciousness, dysfunction of memory around
the time of injury, or loss of consciousness
lasting less than 30 minutes.”

32. mTBI continued
• …“In addition, observed signs of injury to
the head, irritability, lethargy, or vomiting
following head injury, especially among
infants and very young children;
headaches, dizziness, irritability fatigue or
poor concentration, especially among
older children and adults”

33. VisionHelp TBI Concussion
Video: https://www.youtube.com/watch?v=De0gMQ0Fd5U#t=25

34. The Ghost in My Brain:
How a Concussion Stole My Life and
How the New Science of Brain
Plasticity Helped Me Get it Back
•
• Clark Elliott, PhD
• Viking Press (June 2, 2015)

35. • Concussion after car rear-ended
• Overnight went from artificial intelligence
professor to humbled man struggling to get
through the day
• At times he couldn’t walk across a room, or
even name his five children.
• Doctors told him he would never fully
recover.
• After 8 years, cognitive demands of job &
being a single parent, finally became more
than he could manage

36. • Referred finally to 2 brilliant Chicago-area
Clinicians—one an Optometrist specializing
in Vision Therapy & the other a Cognitive
Psychologist—working together on the
leading edge of brain plasticity
• Within weeks the ghost of who he had
been started to re-emerge
The Ghost In My Brain: The
dramatic story of one man’s
recovery offers new hope to
those suffering from
concussions and other brain
traumas

38. Norman Doidge, MD :
The Brains Way Of Healing
"Related to natural vision therapy is
the relatively unknown field of
behavioral optometry, eye doctors
who specialize in Vision Therapy,
which for almost one hundred years
has understood that vision is a group
of skills that can be trained. The
field relies on neuroplasticity.”

39. “The neurobiologist Susan Barry,
Ph.D., spent fifty years with two-
dimensional vision because she had
strabismus - her eyes were
misaligned ... With neuroplasticity-
based training from her behavioral
optometrist, Barry reawakened and
rebalanced her visual cortex and
finally experienced 3-D at the age of
50, as she compellingly described in
her book Fixing My Gaze."

40. Archives of Physical Medicine
and Rehabilitation
“Vision Therapy, Prisms, & Binasal Occlusion
were very helpful in improving binocular
integration, and double vision from
extraocular movement disorders (in TBI
patients).”
Reported in the March, 1998 Archives of Physical
Medicine and Rehabilitation, Volume 79, No. 3
Suppl 1

41. "The ultimate purpose of the visual process is to
arrive at an appropriate motor, and/or cognitive
response. There is an extremely high incidence
(greater than 50%) of visual and visual-cognitive
disorders in neurologically impaired patients
(traumatic brain injury, cerebral vascular
accidents, multiple sclerosis etc.)"
Rosalind Gianutsos, Ph.D NeuroPsychologist

42. • "Visual-perceptual dysfunction is one of the
most common devastating residual impairments
of head injury". Barbara Zoltan, M.A., O.T.R.
• "The majority of individuals that recover from a
traumatic brain injury will have binocular
function difficulties in the form of strabismus,
phoria, oculomotor dysfunction, convergence
and accommodative abnormalities". William
Padula, O.D. Neuro Optometrist

43. Visual midline shift syndrome[i]
Vision is normally matched with kinesthetic, proprioceptive and
vestibular function. Disruption in the coherence of these systems
can cause an individual to no longer visually judge objects that are
located along the patients anatomical midline, to be at their
anatomical midline.
[i] Padula, WV, Argyris, S. Post Trauma Vision Syndrome and
Visual Midline Shift syndrome. NeuroRehabilitation 6 (1996) 165-
171

44. Visual Midline Shift Syndrome
(VMSS)
• occurs when the perception of a
person's concept of visual midline
shifts to the side
• causes the person literally to lean to
the side, forward or backwards
• interferes with all aspects of balance,
coordination and ambulation

45. Visual Midline Shift Syndrome (VMSS)
• A person's perception of his own midline shifts.
• Walls may seem to lean in on him, and his
horizon may slant right or left.
• This syndrome may cause dizziness or nausea,
spatial disorientation, and poor balance or
posture as the person unconsciously leans to
one side or the other to adjust to his perceived
midline or horizon tilt.
• Effectively treated with yoked prisms & vision
therapy

46. YOKED PRISMS SHIFT VISUAL-
VESTIBULAR MIDLINE

47. Eye movement dysfunction
Fixation
Pursuits
Saccades
Nystagmus
Ocular muscle dysfunction
Pupillary defects
Ptosis
Lagophthalmos – poor closure of upper eyelid

48. Binocular dysfunction
Strabismus
Diplopia
Decreased depth perception
Exophoria
Convergence insufficiency
Vertical phoria

49. Accommodative dysfunction
Accommodative insufficiency
Perceptual dysfunction
Photophobia
Agnosia – problems recognizing familiar objects/faces
Visual memory
Visual attention
Visual-motor integration

50. Visual processing abilities
Cognitive deficits are worse when visual processing
problems are not identified or treated[i]
Visually induced balance dysfunction
Visual-vestibular integration
[i] Uzzell BP, Dolinskas CA, Langfitt TW. Visual Field Defecits in
Relation to Head Injury: A Neuropsychological Study. Arch Neurol
1988;45:420-424.

51. Post Trauma Vision Syndrome (PTVS) [i]
• Exotropia, Exophoria
• Convergence insufficiency
• Accommodative insufficiency
• Oculomotor dysfunction
• Double Vision, Headaches, difficulty maintaining eye contact
• Reduction or loss of one half or one quarter of the visual field
• Difficulty reading (words may appear to move, difficulty keeping
track of place on the page)
• Low blink rate, dry eyes, or staring behaviors
[i] Padula, Argyris, Post Trauma Vision Syndrome and Visual Midline Shift
Syndrome. NeuroRehabilitation 6 (1996)165-171

52. PTVS Common symptoms
Diplopia
Blurred near vision
Perceived movement of print or stationary objects
Asthenopia
Headaches
Photophobia

53. Post Trauma Vision Syndrome
& Vision Therapy
• Eye muscle imbalances & Eye alignment
imbalances
• Ambient visual process dysfunction & sensory-
motor spatial disorganization
• Eye turns outward or a strong tendency for both
eyes to diverge. These binocular problems result in
problems in balance, posture, attention, memory,
reading difficulties, words appear to move, etc.
• Effectively treated with therapeutic lenses and
vision therapy

54. Rehabilitation Professional’s
Guide
• Post Trauma Vision Syndrome
• Visual Midline Shift Syndrome
• Dizziness
• Double Vision
• Spatial Disorientation
• Hard to appreciate full screen of computer, TV,
movie
• “I oftentimes feel like I’m going to fall”
• “I get carsick & experience motion sickness”
• “Reading gives me a headache, makes me feel
dizzy, sleepy”

55. Dizziness
A Patient Complaint That Can
Make the Doctor’s Head Spin.

56. What Is Dizziness ?
• A non-specific term used to describe a
number of signs and symptoms
– Unsteadiness
– Giddiness
– Light-headed
– Disequilibrium
– Vertigo

57. Dizziness, Hearing Loss, and
Tinnitus/ Baloh,R.W
1998,F.A.Davis Co
Focus of Diagnostic Workup
• Vertigo – auditory and Vestibular system
• Near-faint dizziness– cardiovascular
system
• Psychophysiological dizziness - psychiatric
• Hypoglycemic dizziness- metabolic
assessment
• Disequilibrium – peripheral nerves, spinal
cord, inner ear, vision, CNS

58. History of the Dizzy Patient
• Detailed description of dizziness
• Differentiate vertigo from non-vertigo
• Determine onset, length, and if recurrent
• Associated neurological or systemic signs
• Any hearing loss?
• Current medications
• Differentiate Peripheral vs. Central cause

59. Differential Diagnosis and
Management for the Chiropractor,
Aspen Publishers, Inc 2001
Peripheral or Central Cause?
Peripheral
• Labyrinth or
vestibular nerve
dysfunction
• Recurrent
• Nystagmus-horizontal
• Position change
• Moderate to severe
vertigo
Central
• Cerebellum or brain
stem dysfunction
• Continuous
• Nystagmus-vertical
• Mild vertigo
• Non-positional

60. Assessment of the dizzy patient,
Australian Family Physician Vol.
31, No. 8, August 2002
Peripheral Vestibular Disorders
• BPPV
• Labrynthitis
• Meniere’s disease
• Acoustic Neuroma
• Motion sickness
• Cervicogenic
• Perilymphatic fistula
• Vestibular neuronitis
• Semicircular canal
infection
• Semicircular canal
water penetration

61. Assessment of the dizzy patient,
Australian Family Physician Vol.
31, No. 8, August 2002
Central Vestibular Disorders
• Brain stem lesion
• Basilar artery
migraine
• TIA
• Stroke
• MS
• Cerebellar lesions
• Metastatic Tumor
• Meningioma

62. Assessment of the dizzy patient,
Australian Family Physician Vol.
31, No. 8, August 2002
Central Vestibular Disorders
• Brain stem lesion
• Basilar artery
migraine
• TIA
• Stroke
• MS
• Cerebellar lesions
• Metastatic Tumor
• Meningioma

63. Causes of Vertigo
• Ear disease
• Toxic conditions (alcohol, food poisonings)
• Postural hypotension
• Infectious disease
• Cervicogenic
• Disease of the eye or brain
• Psychological

64. Australian Family Physician Vol.
31, No 8, August 2002
When to refer to a specialist
• Serious vertigo that is disabling
• Ataxia out of proportion to vertigo
• Vertigo longer than 4 weeks
• Changes in hearing
• Vertical nystagmus
• Focal neurological signs
• Systemic disease or psychological origin

65. A Neuro Optometrist’s
Perspective
The difference between
eyesight and vision
-Eyesight is the ability to see clearly
at 20 feet.
-Vision goes far beyond simply this.

66. The Autistic Spectrum of Disorders
(ASD) from least to most serve:
• ADD (Attention Deficit Disorder)
• ADHD (Attention Deficit Hyperactivity Disorder)
• LD (learning disabilities)
• NLD (non-verbal learning disabilities)
• HFA (high functioning autism)
• AS (Asperger Syndrome)
• PDD (pervasive developmental disorders)
• PDD-NOS (PDD not otherwise specified)
• Autism
Lorna Wing, MD “The Autistic Spectrum”

67. Patients with Autistic Spectrum
Disorders (ASD) have a high
incidence of:
• Strabismus
• Hyper & Hypo reactivity to information
coming in from their touch, movement, &
vestibular system
• Gross & Fine Motor Delays
• Evidence of retained primitive reflexes

68. Signs of Visual Problems in
Individuals with ASD
• Squints or closes one eye
• Stares at certain objects or patterns
• Looks through hands
• Flaps hands, flicks objects in front of
eyes
• Sensitivity to light (photophobia)
• Looks at objects sideways or with
quick glances

69. Signs of Visual Problems in
Individuals with ASD continued…
• Pushes or rubs eyes
• Confused at changes in flooring or
stairways
• Difficulty making eye contact
• Bumps into objects
• Widens eyes or squints when asked
to look
• Touches walls/tables while walking
• Obsession with lights & shadows

70. ASD & Central/Peripheral
Vision Coordination
• Children with autistic spectrum disorders tend to
use one or the other…not both simultaneously
• Central (focal) Processors can fixate on a central
point of focus for excessive periods of
time…obsessed with details, staring at a stick in
their central field
• Peripheral (ambient) Processors can spend hours
staring at high contrast, moving, lights,
shadows, shiny objects

71. Poor Integration of
Central/Peripheral Vision can lead
to…
• Difficulties in focusing, attention, spatial
organization, and visual perception
• Developing compensatory techniques to
deal with their faulty view of the world like
toe walking, walking while touching or
holding onto walls, hand flapping

72. Kids' eye problems often
emerge in homework battle
New Research on Convergence
Insufficiency (CI)
Archives of Ophthalmology October,
2008;126(10):1336-1349
NIH funded
Multi Million Dollar, Multi Center
Placebo Controlled
Definitive relationship between CI and ADHD

73. The Vestibular System
In essence,
the vestibular system
is the orienting system
for the
auditory and visual systems
in time and space

74. The Vestibular System
A motor center to move around
three dimensionally.
An emotional center for self-regulation
A perceptual center so we are not
lost in space.
A spatial-temporal center with which
to relate to objects, people,
and events in our world.

75. Visual Dysfunctions Causing
Dizziness & Balance Problems
• Aneisokonia
• Vertical Imbalance
• Binocular Vision Dysfunction
• Double Vision
• Ambient Visual Disorder
• Eye Movement Disorders

76. Visual field Deficits
• Occur in about 40 % of patients with TBI
• Occur in about 67 % of patients with CVA
Cerebral Vascular Accident & most (30 %)
are homonymous

77. Therapeutic interventions for visual dysfunction
Patching
Selective sector
Opaque
Translucent

82. Lenses
Prism
Fresnell
Ground in
Yoked[i]
Tints
Refractive error
[i] Rossetti, Y, Rode, G, Pisella, L, Farne, A, Li, Boisson, D, Perenin, M-
T. Prism Adaptation to a Rightward Optical Deviation Rehabilitates Left
Hemispatial Neglect Nature Vol 395 Sep 1998; 166-169

88. Field awareness prism[i]
Spot
Ribbon
[i]Gottlieb, DD, Fuhr, A, Hatch WV, Wright, KD, Neuro-
optometric Facilitation of Vision Recovery After Acquired Brain
Injury NeuroRehabilitation 11 (1998) 175-199

92. Vision Rehabilitation[i]
Hemianopsia treatment protocol
Binocular fusion therapy
Ocular motility therapy
Visually guided movement
[i] Raymond, MJ, Bennett, TL, Malia, KB, Bewick, KC.
Rehabilitation of Visual Processing Deficits Following Brain Injury.
NeuroRehabilitation 6 (1996) 229-240

93. Impairment Disability
• Hemianopsia
• Diplopia
• Visual Midline Shift
• Poor saccades
• Slow visual-motor
response
• Shop in mall
• Dial phone
• Walks into furniture
• Difficulty reading
• Unable to drive

94. Vision Therapy at San Diego
Rehabilitation Institute
http://youtu.be/vUIjL
oNaZFE
Visual Vestibular
Therapy

95. A Review of the Latest Research
into Vision Therapy
• Archives of Ophthalmology 2005; 123:437-447:
NIH study confirms “it is never too late to treat a “Lazy eye with
vision therapy”
• Archives of Ophthalmology 2005; 123:14-24:
Controlled Study Demonstrates Value of Optometric Vision Therapy
 Strabismus, December, 2005; 13 (4): 163-168
New Research study confirming link between Binocular Vision
Problems and ADHD
• Learning Disabilities Association Journal, 2004:
Article Shows Benefits of Vision Therapy
• Journal of Learning Disabilities, Nov. 2003:
Vision Therapy improves Reading Comprehension
www.visionhelp.com

96. Plasticity
• “Recent evidence from a number of state-
of-the-art laboratories for neurobiology
indicates that visual, tactile, and motor
systems remain modifiable to a significant
degree well into adulthood.”
– Thomas Albright, Ph.D The Salk Institute For
Biological Studies

97. USA TODAY January 27, 2011
'Happy that I'm still alive'
Wounded veteran Patrick Horan works with Dr. Bryce
Appelbaum as Horan's wife, Patty, looks on during vision
therapy in Bethesda, Md www.USAToday.com

102. What is vision therapy?
Is it strength training for the eyes?
Well, not exactly…

103. Vision Therapy and Rehabilitation

104. What is vision therapy?
“Vision therapy is a sequence of neurosensory and
neuromuscular activities individually prescribed and
monitored by the doctor to develop, rehabilitate and
enhance visual skills and processing.”
- American Optometric Association
“Unlike other forms of exercise, the goal of
optometric vision therapy is not to strengthen eye
muscles.”
-College of Optometrists in Vision Development

105. What is vision therapy?
physical & occupational therapy for the eyes with a
cognitive component

106. Our Population
We primarily treat
• Children with ADHD
• Mild traumatic brain injury/concussions
• Learning and reading disabilities (reluctance to read)
• Autism Spectrum Disorder

107. Vision Therapy- Delivery of care
• Office-based
• Provided by a Doctor of Optometry –
Doctor is in the therapy room
• Board Certified, FCOVD
– Vision therapy assistants
• Generally 50 minute sessions- 1-2 x/week
• Home reinforcement

108. Duration of treatment
• Based on diagnosis
• Complicating factors

109. Lenses and Prisms

110. Lenses
• The role of the lens
– Refractive correction-
– Aid accommodation-
• Influence binocular vision via AC:A
– Aid spatial awareness
– Aid peripheral awareness
– Aid focal-ambient integration
• http://maunsell.med.harvard.edu/Downloads/publications/87bMaunsell.pdf
• http://www.oepf.org/jbo/journals/2-1%20Marrone.pdf

111. Prisms – Vertical & Horizontal

112. Yoked Prisms

113. Chairside Screening
• What gets tired first, your eyes or
your body ?
• Reluctant or Avid Reader ?
• King-Devick Concussion Screening
Eye Movement Test

114. Southern College of Optometry
Residency in Vision Therapy and
Vision Rehabilitation in a Private
Practice
• Only fully accredited Optometric
Residency in the Washington, DC area
is at AppelbaumVision.com
Bethesda & Annapolis, Md.
• Stan Appelbaum, OD, FCOVD Supervisor
• Thanks for referring interested OD
students

115. • Vision Rehabilitation: Multidisciplinary Care
of the Patient Following Brain Injury –
edited by Suter & Harvey (2011)

116. Vision Therapy
• Brock String
• Matrix
• Thumb Rotations
• Three Thumbs
• Red/Green Flashlight
• Peripheral Vision Expansion

119. Huang JC. Neuroplasticity as a Proposed
Mechanism for the efficacy of optometric
therapy & rehabilitation.
J Behav Optom 2009; 20(4):9-99.
• The scientific community is gradually embracing the
notion that rehabilitation of motor, sensory and cognitive
impairments can alter brain reorganization and result in
functional recovery.
• The training and rehabilitation of functional visual
disorders through repetitive, targeted visual
rehabilitative techniques should not be a foreign
concept.
• Based on what is now known about neuroplasticity, the
mechanism for the efficacy of VT and rehabilitation is
likely through strengthening synaptic connections and
inducing cortical reorganization to maximize visual
efficiency.

121. Brain Injury Medicine:
Principles and Practice
Nathan D. Zasler
Douglas I. Katz
Ross D. Zafonte
Demos Medical
Publishing 2006
p. 511-528 “Evaluating &
Treating Visual Dysfunction,”
Padula, Wu, Vicci

123. EYE POWER . . . a cutting edge
report on VISION THERAPY
Ann M. Hoopes &
Stanley A. Appelbaum, OD, FCOVD
Improve your visual attention, vitality, stamina,
mental efficiency, and productivity for a better
quality of life.
www.EyePowerBook.com

124. Resources
Neuro-Optometric Rehabilitation Association
www.nora.cc (NORA)
VisionHelp Network
www.VisionHelp.com

125. Because…life takes vision

126. Questions? Contact:
Stan Appelbaum, OD, FCOVD
Bryce Appelbaum, OD, FCOVD
Barbara S. Bassin, OTR/L, BCP
Sensory Integration & Vision Therapy
Specialists
Bethesda & Annapolis Maryland
301-897-8484
www.VisionHelp.com
www.AppelbaumVision.com